Tomoyuki Ushijima

Endoscopic bile duct and/or pancreatic duct cannulation technique for patients with surgically altered gastrointestinal anatomy

There are two major hurdles to carrying out endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered gastrointestinal anatomy (Billroth II gastrectomy [B‐II], Roux‐en‐Y anastomosis [R‐Y] etc.), post‐pancreatoduodenectomy or post‐choledochojejunostomy. These are: (i) the endoscopic approach to the afferent loop, blind end, and the site of bilio‐pancreatic anastomosis; and (ii) bile duct and/or pancreatic duct cannulation. Balloon‐assisted enteroscopy (BAE) became available in recent years and is now being actively used to overcome the first hurdle and, at least, the success rate has improved. However, room for improvement still remains in regards to the second hurdle (i.e. the success rate of cannulation of the bile duct and/or pancreatic duct), and there has been a desire for the development of dedicated devices (ERCP catheters, hoods etc.) and for improvement in the functionality of the enteroscopes etc. In the present review, we explain the basic procedure for bile duct and/or pancreatic duct cannulation with conventional endoscopes and BAE, and modifications of the basic procedure.

Technique of reintervention for stent dysfunction in patients with malignant hilar biliary stricture

At present, the endoscopic approach is the most commonly adopted method for stenting in patients with unresectable malignant hilar biliary stricture. This procedure is important, as it determines the quality of life and prognosis of the patient. Regarding the quality of the stent material, self‐expandable metallic stents (SEMS) are expected to show longer‐term stent patency than plastic stents (PS), and their use as devices of first choice has been increasing. However, complications such as stent occlusion due to tumor ingrowth or biliary sludge formation occur at a considerably high frequency, necessitating reintervention in a considerable number of patients. In the case of dysfunction of an implanted PS, the stent is removed, and the lumen ofthe bile duct is cleaned, followed by placement of a new stent. In the event of dysfunction of a SEMS, cleaning of the lumen of the SEMS and placement of a second stent (PS is preferable) are carried out. Nevertheless, the results have not been entirely gratifying. Development of SEMS or PS suited to multidisciplinary treatment that would enable uncomplicated reintervention is anticipated.

Evaluation of magnifying endoscopy using narrow band imaging using ex vivo bile duct (with video).

Detailed endoscopic findings of the bile duct mucosa, even of the non‐neoplastic mucosa, have not yet been established. The aim of the present study was to compare a currently used video cholangioscope (CCS) with a magnifying endoscope (ME) that is commonly used for the gastrointestinal tract, for visualization of the bile duct mucosa.

mFOLFOX6 Chemotherapy after Resection of Anal Canal Mucinous Adenocarcinoma

Because of their rarity, there are no clear guidelines for the treatment of anal carcinomas; such tumors are normally subjected to the same modalities as recommended for rectal cancer. We report a patient with anal canal mucinous adenocarcinoma, with metastases in the pararectal and right inguinal lymph nodes, who was treated with abdominoperineal resection followed by mFOLFOX6 chemotherapy for 6 months (12 cycles). The patient has remained recurrence-free thus far, approximately 2 years since the surgery. As the optimal treatments for anal carcinomas have not been fully elucidated, we present this case to highlight a possible course of action for such patients that appears to be effective and promising.

Abstract 3955: Expression of cancer stem cell-associated proteins in exosomes derived from ascites of patients with advanced pancreatic cancer

Background: The number of patients with pancreatic cancer is rapidly growing, and the disease is the fifth leading cause of cancer-related death in Japan. At end stage of the disease, the patients are prone to suffer peritonitis carcinomatosa with chemorefractory ascites. It is known that cancer cells surviving in ascites show cancer stem cell (CSC)-like features (PLoS One 2012). The CSC-like cells robustly secrete extracellular vesicle called exosome, which plays important roles in tumorigenesis, tumor growth, metastasis, angiogenesis, pre-metastatic niche formation, immunosuppression, drug resistance, and epithelial-mesenchymal transition. The AIM of this prospective study was to assess whether exosomes taken from malignant ascites of patients with advanced pancreatic cancer included the CSC-associated proteins, that might be predictive markers for chemoresistance and prognosis. Methods: The malignant ascites was collected from the cancer patients who underwent abdominocentesis and/or cell-free and concentrated ascites reinfusion therapy (CART) in Kurume University Hospital. Ascites derived from patients with benign diseases, including decompensated liver cirrhosis (d-LC), was used as control. Informed consent was obtained from all of the patients. Exosomes in ascites were purified by using ExoQuick Exosome Precipitation Solution (System Biosciences) according to the manufacturer9s protocol. Western blot analysis was performed to detect CSC-associated proteins, including CD133, CD44, CD44v9, xCT, CD24, and Dclk1. Results: Successful purification of exosomes from both the malignant ascites and the benign one was confirmed by monitoring exosome-specific proteins such as CD68, CD9, CD81, and HSP70. Among the CSC-associated proteins examined, CD133 was predominantly expressed in exosomes obtained from ascites of the pancreatic cancer patients compared with those obtained from ascites of the d-LC patients. Other molecules were faintly expressed or absent even in the malignant ascites. Conclusions: We first demonstrated abundant expression of CD133, a human pancreatic CSC marker, in exosomes derived from ascites of patients with the disease. The finding suggests that exosomal CD133 might be a potential biomarker for chemoresistance and prognosis of the patients. Citation Format: Takahiko Sakaue, Hironori Koga, Masaru Fukahori, Yasuko Imamura, Toru Nakamura, Yoshinobu Okabe, Yu Ikezono, Fumitaka Wada, Hideki Iwamoto, Atsutaka Masuda, Tomoyuki Ushijima, Keisuke Miwa, Tatsuyuki Kakuma, Osamu Tsuruta, Takuji Torimura. Expression of cancer stem cell-associated proteins in exosomes derived from ascites of patients with advanced pancreatic cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3955.

Trousseau's syndrome in a patient with gastric cancer.

A 74-year-old man, who had been receiving S-1 plus cisplatin combination chemotherapy for gastric cancer and metastatic disease of the liver,1 developed disorientation, amnesia and anorexia on day 13 of the fourth cycle of the chemotherapy regime. On day 16, he was reviewed in the outpatients department and was admitted as an emergency. MRI of the brain obtained on his admission showed no metastatic …

A case of gastric wall implantation caused by EUS-FNA 22 months after pancreatic cancer resection

The patient was a 78-year-old woman in whom abdominal ultrasonography in a medical examination revealed dilatation of the main pancreatic duct. She, therefore, attended our hospital. Computed tomography (CT) [Figure 1] and magnetic resonance imaging (MRI) revealed a mass lesion 10 mm in diameter in the pancreatic body. EUS-FNA was performed using a 25-gauge needle [Figure 2], leading to a cytological diagnosis of adenocarcinoma. Distal pancreatectomy with splenectomy was followed by adjuvant systemic chemotherapy with S-1 for 1 year. Histopathological diagnosis of the surgically resected specimen was well-differentiated tubular adenocarcinoma (T3N0M0, Stage IIA), and there was no remnant of cancer in intraoperative or pathological findings. CT and/or MRI were repeated performed every 3–5 months until 18 months after resection showed no evidence of tumor recurrence or metastasis.

Erythema multiforme induced by regorafenib

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Successful Treatment of Metastatic Anal Canal Adenocarcinoma with mFOLFOX6 + Bevacizumab

Anal canal adenocarcinoma is a relatively rare malignancy without established diagnostic and treatment criteria. Case reports of chemotherapy for anal canal adenocarcinoma with distant metastasis are limited, and there is no convincing evidence for treatment effectiveness. A 62-year-old man complained of difficulty in defecation, anal pain, and bleeding during bowel movement. He was diagnosed with moderately differentiated primary anal canal adenocarcinoma. A computed tomography scan revealed multiple metastases in the lung and liver. The patient was treated with abdominoperineal resection to control local tumor growth and then with chemotherapy consisting of mFOLFOX6 + bevacizumab. Because he had an activating KRAS mutation, anti-EGFR therapy was not considered. A reduction in the size of lung and liver metastases was observed after 4 courses of mFOLFOX6 + bevacizumab, and after 22 courses, maximum reduction in the metastatic lesions was achieved. The patient demonstrated tolerable levels of oxaliplatin-related peripheral neurotoxicity (grades 1-2) and was considered as having partial response to treatment. He is currently at the partial response state for 1 year. We plan to continue the treatment unless the patient develops progressive disease or intolerable adverse reactions. This case demonstrates that anal canal adenocarcinoma with distant metastases could be successfully treated with mFOLFOX6 + bevacizumab therapy according to the guidelines for rectal carcinoma. However, as anal canal carcinoma has multiple histological subtypes, it is important to establish subtype-specific treatment strategies.

CT images of enterohaemorrhagic Escherichia coli colitis

A 74-year-old woman who had undergone surgery for rectal cancer and also had lung metastases developed abdominal pain, diarrhoea and bloody stools 5 days after receiving her 22nd dose of S-1, oxaliplatin and bevacizumab therapy.1 She was admitted to the hospital with a suspected adverse reaction to chemotherapy and infectious enteritis. CT imaging …